Provider Demographics
NPI:1669443966
Name:DRENGENBERG, DEBRA C (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:C
Last Name:DRENGENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:C
Other - Last Name:COOPERSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1107 S DIVISION AVE
Mailing Address - Street 2:KSB CENTER FOR HEALTH SERVICES/POLO
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-1875
Mailing Address - Country:US
Mailing Address - Phone:815-946-3453
Mailing Address - Fax:815-946-3908
Practice Address - Street 1:1107 S. DIVISION AVE.
Practice Address - Street 2:KSB CENTER FOR HEALTH SERVICES/POLO
Practice Address - City:POLO
Practice Address - State:IL
Practice Address - Zip Code:61064
Practice Address - Country:US
Practice Address - Phone:815-946-3453
Practice Address - Fax:815-946-3908
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL88519OtherMEDICARE
IL036101870Medicaid
G66699Medicare UPIN